Physiological Integrity

A client is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following a bowel resection. During hourly rounds, the nurse notes the client has a respiratory rate of $8 \text{ breaths/minute}$, pinpoint pupils, and is unresponsive to physical stimulation. The nurse immediately stops the PCA pump, calls for assistance, and receives a verbal prescription for naloxone $0.4 \text{ mg}$ IV stat. Which action by the nurse demonstrates the safest administration technique for this medication?

A triage nurse evaluates a client presenting with a 4-day history of frequent, watery diarrhea and an inability to drink fluids. The client is lethargic and exhibits delayed capillary refill. Assessment reveals a heart rate of 124 beats/minute, a respiratory rate of 30 breaths/minute with deep chest excursions, and a blood pressure of 94/76 mm Hg. Arterial blood gas (ABG) testing indicates a pH of 7.25, PaCO2 of 27 mm Hg, HCO3 of 12 mEq/L, and PaO2 of 96 mm Hg on room air. Which of the following actions should the nurse perform FIRST?

A nurse is developing a plan of care for a client who will be returning to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should be included to reduce the risk of post-procedure complications? Select all that apply.

A registered nurse (RN) is caring for a critically ill client diagnosed with sepsis. The client's current vital signs include a blood pressure of $88/54\text{ mmHg}$, heart rate of $112\text{ beats/min}$, and a temperature of $38.9^\circ\text{C}$ ($102^\circ\text{F}$). The client is receiving a continuous intravenous (IV) infusion of dopamine through a single-lumen peripheral IV catheter to maintain hemodynamic stability. The healthcare provider prescribes a new intermittent IV piggyback of piperacillin-tazobactam. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral practices? (Select all that apply.)

A nurse is caring for a 72-year-old client in the intensive care unit, 12 hours post-coronary artery bypass graft (CABG) surgery. The client was extubated 4 hours ago. Over the last hour, the mediastinal chest tube drainage has abruptly decreased from 120 mL/hr to 10 mL/hr. The client's current physiological data are as follows:

- Blood pressure: 86/68 mmHg
- Heart rate: 124 bpm
- Respiratory rate: 26 breaths/min
- Central Venous Pressure (CVP): 15 mmHg (baseline was 6 mmHg)
- Arterial Blood Gas (ABG): pH 7.30, $PaCO_2$ 32 mmHg, $PaO_2$ 82 mmHg, $HCO_3^-$ 15 mEq/L
- Assessment: Heart sounds are muffled, and the client is increasingly restless.

Based on the interpretation of this clinical data, which of the following actions should the nurse take FIRST to reduce the risk of severe physiological decompensation?

A nurse is caring for a 45-year-old client who is 4 hours post-operative following an abdominal hysterectomy. Over the last hour, the client's blood pressure has trended from $124/76$ mm Hg to $110/84$ mm Hg, and the heart rate has increased from $78$ to $115$ beats/min. The client's arterial blood gas (ABG) results on room air are: pH $7.38$, PaCO2 $40$ mm Hg, HCO3 $24$ mEq/L, and PaO2 $92$ mm Hg. The client reports mild incisional pain. Which of the following actions should the nurse take first?

A nurse is caring for a 65-year-old client admitted with a heart failure exacerbation and a suspected systemic infection. The client has a continuous peripheral intravenous (IV) infusion of Lactated Ringer's solution running at 75 mL/hr. The client's current vital signs are blood pressure 138/85 mmHg, heart rate 92 beats/min, and respiratory rate 18 breaths/min. The healthcare provider has prescribed several new IV medications to manage the client's condition. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral therapy principles? Select all that apply.

A clinical nurse evaluates a client who is $8$ hours post-operative following a laparoscopic Roux-en-Y gastric bypass. Which of the following nursing actions or clinical judgments are appropriate to reduce the risk of physiological decompensation? (Select all that apply.)

A nurse is preparing to administer an oral suspension of amoxicillin to a pediatric client who weighs $33$ lb. The provider's prescription is for $20$ mg/kg/dose. What is the amount, in milligrams, the nurse should administer for a single dose? (Record your answer as a whole number.)

A nurse is discontinuing a client's central venous catheter (CVC). Immediately after the catheter is removed, the client gasps, reports sudden severe chest pain, and becomes distinctly cyanotic. The nurse suspects a venous air embolism. Arrange the following nursing interventions in the correct order of priority from first to last.

A nurse is evaluating a client who underwent a percutaneous liver biopsy two hours ago. The client is currently resting in a supine position. The latest vital signs reveal a blood pressure of 102/64 mm Hg, a heart rate of 118 bpm, and a respiratory rate of 20 breaths per minute. The client's baseline heart rate before the procedure was 76 bpm. Which of the following actions should the nurse take first to reduce the risk of a severe complication?

A young adult client is admitted to the orthopedic trauma unit following a closed fracture of the right femoral shaft sustained 18 hours ago. The client is currently in skin traction awaiting surgical fixation. Which of the following assessment findings indicate the development of a life-threatening systemic complication requiring immediate intervention? Select all that apply.

A nurse is evaluating a client who was admitted with severe acute pancreatitis. The client develops sudden, severe dyspnea, and the healthcare provider suspects the onset of Acute Respiratory Distress Syndrome (ARDS). Which of the following assessment and diagnostic findings would support a diagnosis of ARDS? Select all that apply.

A client with a severe exacerbation of Crohn's disease is receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes an intravenous (IV) push dose of famotidine every 12 hours. Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is developing a plan of care for a 75-year-old client who is on strict bed rest due to severe weakness from bacterial pneumonia. The client has also begun experiencing sudden periods of confusion in the evenings. Which of the following interventions should the nurse include in the plan of care? Select all that apply.

A 64-year-old client is admitted to the progressive care unit 2 hours after a percutaneous coronary intervention (PCI) via the right femoral approach. During the focused assessment, which clinical findings indicate to the nurse that the client is experiencing a potential complication requiring immediate intervention? (Select all that apply.)

A client recovering from an ischemic stroke with left-sided hemiparesis and mild dysphagia is cleared to begin a soft oral diet. Which nursing action represents the safest approach to managing this client's nutritional intake?

A nurse is caring for a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client reports severe lower back pain, chills, and shortness of breath. The nurse assesses a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$) and a heart rate of $118\text{ beats/min}$. Which of the following actions should the nurse take? (Select all that apply.)

An intensive care nurse is monitoring a client who is receiving continuous total parenteral nutrition through a right subclavian central venous access device. While assessing the client, the nurse discovers that the intravenous tubing has completely disconnected from the catheter hub. The client is acutely restless, exhibiting perioral cyanosis, and auscultation reveals a loud, churning "mill-wheel" murmur over the precordium. The client's heart rate is $138$ beats per minute and blood pressure is $82/46$ mmHg. To mitigate the risk of a fatal physiological outcome, which sequence of actions must the nurse execute immediately?

A client with type 1 diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). The client is lethargic, exhibits Kussmaul respirations, and reports severe abdominal pain. Initial laboratory results indicate a blood glucose of 610 mg/dL (33.9 mmol/L) and a serum pH of 7.15. The healthcare provider prescribes a comprehensive DKA treatment protocol. Arrange the following nursing interventions in the correct chronological order of implementation.